Benefits employee 2021 - guide - Galveston, TX
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2021 employee benefits guide
Table of Contents Table of Contents ............................................................................................................................................................................. 2 Take Care of Your Tomorrow!......................................................................................................................................................... 3 Open Enrollment Benefits Center................................................................................................................................................... 4 Benefits Resource List ...................................................................................................................................................................... 5 Eligiblity ............................................................................................................................................................................................. 6 Medical Benefits ............................................................................................................................................................................... 7 Health Reimbursement Account (HRA) ......................................................................................................................................... 8 Flexible Spending Account.............................................................................................................................................................. 9 MDLive - Telemedicine .................................................................................................................................................................. 10 utmb Health – Connect 2-Care ..................................................................................................................................................... 11 Dental Benefits – Voluntary Plan .................................................................................................................................................. 12 Vision Benefits – Voluntary Plan ................................................................................................................................................... 13 Basic Life & AD&D Benefits .......................................................................................................................................................... 14 Voluntary Life & AD&D Benefits .................................................................................................................................................. 15 Voluntary Permanent Life Insurance ............................................................................................................................................ 16 Aflac Voluntary Benefits .................................................................................................................................................................17 Employee Assistance Program (EAP) ........................................................................................................................................... 18 Making Enrollment Changes During the Year What Constitutes a Qualifying Life Event?................................................... 19 Page | 2
Take Care of Your Tomorrow!
The City of Galveston provides you with the freedom to select quality benefit options that work best for
you and your family.
It works only if you take an active role and make thoughtful decisions about your benefits coverage. This
way, you can be sure your benefits support your needs and goals.
It is important that you take an opportunity to review all of your plan options in detail. You will need to
carefully consider each benefit option, its cost and value to you and whether it is appropriate for your
personal needs. By taking the time to examine all of your options, you will ensure that your benefits meet
your needs and the needs of your family throughout the plan year.
The City of Galveston values our employees and recognizes the importance of offering a comprehensive,
cost-effective, and competitive benefits package that enhance the health and wellness of our employees
and their families.
.
Please Keep This Guide
It is a valuable resource for you throughout the year.
Page | 3
Open Enrollment Benefits Center Page | 4
Benefits Resource List
For more information on the wide range of the City of Galveston benefits, programs and tools, contact
the following resources:
If You Have Questions About Contact By Phone On the Internet
Medical Coverage BlueCross BlueShield
800-521-2227 www.bcbstx.com
Of Texas
Telemedicine
MD Live 888-680-8646 www.bcbstx.com
Prescription Drugs
Prime Therapeutics 877-794-3574 www.myprime.com
Dental Coverage
Humana 877-877-1051 www.humana.com
Vision Coverage
Humana 877-877-1051 www.humana.com
Life/AD&D Insurance
Standard 800-628-8600 www.standard.com
Basic & Voluntary
Accident, Critical Care, Cancer & Aflac 713-789-6920
rmw2@flash.net
Short Term Disability Coverage Roberta Wiedeman 713-449-2477
Employee Assistance Program
UT EAP 800-346-3549 www.uteap.com
457b Plan Nationwide-Eric Burson 832-326-0349 bursoe1@nationwide.com
Edward Jones-David Rogers 409-744-1769 david.rogers@edwardjones.com
529 Education Savings Plan
Edward Jones-David Rogers 409-744-1769 david.rogers@edwardjones.com
Permanent Life Insurance
Chubb 855-241-9891 www.chubb.com
NOTICE: This booklet gives you an overview of the main features of your benefit plans. The plans are administered
according to legal plan documents and insurance contracts. Although we’ve tried to summarize the provisions of these
legal documents clearly and accurately, if any information presented here conflicts with the legal documents, the legal
documents will govern. For more detailed information on the plans and your legal rights under the plans, be sure to read
the summary plan descriptions. All benefit plans are subject to change from time to time and The City of Galveston
reserves the right to amend or cancel any benefits described in this booklet, with or without notice. This document does
not guarantee any benefits and is not a contract.
Page | 5
Eligiblity
If you are an active full-time employee, you are eligible to participate in the City’s benefit plans.
Dependent Eligibility - Who can you cover on your benefit plans?
You may cover your legal spouse on our medical, dental, vision, and life insurance plans. If your spouse is a benefit
eligible employee at the City of Galveston, you may not cover him/her under spouse life insurance. Children’s
eligibility varies by plan.
Medical Insurance: A child may be covered under our medical plan through the end of the month during which
he/she reaches age 26. Student status does not affect eligibility for medical coverage. If qualified, disabled older
age dependent children are eligible.
Dental and Vision Insurance: A child may be covered under our dental and vision plan through the end of the month
during which he/she reaches age 26. Student status does not affect eligibility for dental and vision coverage. If
qualified, disabled older age dependent children are eligible.
Life Insurance: A child may be covered under our voluntary life insurance plan through the end of the day before
which he/she reaches age 26.
Flexible Spending Accounts: Claims incurred by you, your spouse, and qualifying child are reimbursable under an FSA.
You must cover yourself on any plans that you wish to enroll a dependent(s) in. See the Summary Plan Descriptions for more
information about dependents and their eligibility.
Dependent Verification Required
Documentation will be required to enroll a dependent in medical, dental or vision coverage. Verification of a
dependent can range from a copy of a birth certificate, copy of a marriage license, or a copy of your most recent
tax return proving the dependent relationship.
You are unable to make
changes to your benefit
selections during the Plan
Year unless you have a
Qualifying Life Event, such
as marriage, birth of a child
or adoption of a child.
Page | 6
Medical Benefits
Effective January 1, 2021
This is a snapshot of the coverage offered through the 2021 medical plan.
BENEFITS – BlueCross BlueShield of Texas PPO Plan – Group Number 274037
Deductible Network $1,500 Individual/$4,500 Family
Non-Network $5,000 Individual/$20,000 Family
Out-of-Pocket Maximum Includes Deductible
Network $5,000 Individual/$15,000 Family
Non-Network Unlimited Individual/Unlimited Family
Co-insurance Network 80%
Non-Network 50%
Lifetime Maximum Unlimited
You Pay
Office Visit Network $0 PCP/$50 Specialist
Non-Network Deductible/50%
Wellness Visit Network $0 Copay
Non-Network Not Covered
In-Patient & Out-Patient Hospital Network Deductible/20%
Non-Network Deductible/50%
Urgent Care Network Deductible/80%
Non-Network Deductible/50%
Emergency Room Facility Charge Network $70 Copay/20%
Non-Network $70 Copay/20%
Retail Prescriptions Generic $0
Preferred/Non-Preferred Brand $50 / $80
Specialty Drug $0 / $50 / $80
Mail Order (90 Days) $0 / $100 / $160
PPO Network Provider List www.bcbstx.com or (800) 810-2583
NOTE: This is a brief summary and not intended to be a contract.
Employee Pays
Coverage Type Total Monthly Cost City Pays Monthly Employee Pays Monthly
24 Pay Periods
Employee Only $725.00 $675.00 $50.00 $25.00
Employee + Family $1,120.00 $790.00 $330.00 $165.00
Page | 7
Health Reimbursement Account (HRA) Effective January 1, 2021 The City of Galveston will contribute $500.00 per year in your HRA. The $500 per employee amount will be available once $1,000 of the deductible has been met. The Health Reimbursement Account (HRA) is the employer-funded account that reimburses employees for qualified medical expenses once $1,000 of the deductible has been met. Employees can use a Health The Health Reimbursement Account (HRA) is the employer-funded account that reimburses employees for qualified medical expenses once $1,000 of the deductible has been met. Employees can use a Health Reimbursement Account (HRA) to pay for medical expenses that are not reimbursed through insurance or any other arrangement. With an HRA, employees will have an employer-funded account that reimburses employees for qualified medical expenses. Unused funds will not roll over year to year. Funds will reset annually along with the deductible. Eligible expenses incurred for the current 2020 plan year can be submitted for reimbursement up until March 15, 2021. Page | 8
Flexible Spending Account
Effective January 1, 2021
A Flexible Spending Account, or FSA, lets you set aside pre-tax money from your paychecks to spend on out-of-
pocket healthcare expenses (i.e. co-pays, deductibles, over-the-counter items, etc.,). Money that goes into an FSA
is pre-tax, so by anticipating your family’s health care and dependent care costs for the next year, you can actually
lower your taxable income.
Health Care Reimbursement FSA
This program lets employees pay for certain IRS-approved medical care expenses not covered by their insurance
plan with pre-tax dollars. The annual maximum amount you may contribute to the Health Care Reimbursement FSA
is $2,750. Some examples include:
Deductible, Prescriptions & Doctor Visit Co-Payments
Over-the-Counter Medicines with a Prescription
Vision services, including Lasik Eye Surgery, Glasses & Contacts
Hearing services, including hearing aids and batteries
Orthodontics, Dental deductibles and coinsurance
Acupuncture
Dependent Care FSA
The Dependent Care FSA allows employees to use pre-tax dollars towards qualified dependent care for children
under the of age 13 or caring for elders. The annual maximum amount you may contribute to the Dependent Care
FSA is $5,000 for 2021, (or $2,500 if married and filing separately).
Examples include:
The cost of child or adult dependent care
The cost for an individual to provide care either in or out of your house
Nursery schools and preschools (excluding kindergarten)
The City of Galveston FSA Plan has a 2½ month grace period applicable to the Health Care and Dependent Care
FSA Accounts. It begins on January 1, 2021 and lasts for two and a half months, until March 15, 2021. Any eligible
expenses incurred during this grace period can be reimbursed with funds remaining in the FSA from the prior 2020
Plan Year.
Remember, any unused money in an FSA at the end of the Plan Year and still remaining after the 2½ month grace
period is forfeited.
Page | 9
eimbursed through insurance or any other arrangement. With an HRA, employees will have an employer-funded account that reimburses MDLive - Telemedicine Page | 10
utmb Health – Connect 2-Care
Page | 11Dental Benefits – Voluntary Plan
Effective January 1, 2021
This is a snapshot of the coverage offered through the 2021 dental plan.
BENEFITS - Humana Dental PPO
Type I – Preventive Services No Deductible/ 100%
Oral examinations (2 Per Year)
Bitewing x-rays
Routine Cleanings (2 Per Year)
Type II – Basic Services Deductible/ 80%
Amalgam Fillings
Tooth Extractions
Periodontics & Endodontics
Type III – Major Services Deductible/ 50%
Crowns
Bridge-work
Dentures
Implants
Type IV - Orthodontia 50% Up To A $1,000 Lifetime Maximum.
Children Up To Age 19 Only.
12 Month Waiting Period for New Hires
Annual Deductible
Individual $50
Family $150
Annual Maximums
Dental Annual Maximum $1,500
(30% coinsurance applied to preventive, basic and
major services once maximum is reached)
Network Humana PPO Network
Late Applicants have a 12 Month Waiting Period for Types II, III and IV Expenses.
Dental Charges are capped at the PPO Level of Reimbursement. Always uses PPO Dentists for maximum benefits. Out-
of-Network Dentists will be subject to the same allowable charge level as In-Network Dentists. Amounts in excess of the
allowable charge level will not be eligible for reimbursement and will be the full responsibility of the insured.
NOTE: This is a brief summary and not intended to be a contract.
Employee Pays
Coverage Type Total Monthly Cost City Pays Monthly
24 Pay Periods
Employee Only $29.34 $0.00 $14.67
Employee + One $55.52 $0.00 $27.76
Employee + Family $78.78 $0.00 $39.39
Page | 12Vision Benefits – Voluntary Plan
Effective January 1, 2021
This is a snapshot of the coverage offered through the 2021 vision plan.
BENEFITS – Humana Vision
Eye Exam Network $10 Copay
Non-Network Up to $30 Reimbursement
Frames/ Lens
Single Vision Network $15 Copay
Non-Network Up to $25 Reimbursement
Bifocal Lenses Network $15 Copay
Non-Network Up to $40 Reimbursement
Trifocal Lenses Network $15 Copay
Non-Network Up to $60 Reimbursement
Lenticular Lenses Network $15 Copay
Non-Network Up to $100 Reimbursement
Frames Network Up to $130 Allowance (20% off above $130)
Non-Network Up to $65 Reimbursement
Contacts *In Lieu of Glasses
Network Medically Necessary Covered at 100%
Elective Up to $130 Allowance
Non-Network Medically Necessary Up to $200 Reimbursement
Elective Up to $104 Reimbursement
Exam Frequency 12 Months
Lens or Contacts Frequency 12 Months
Frames Frequency 12 Months
NOTE: This is a brief summary and not intended to be a contract.
Employee Pays
Coverage Type Total Monthly Cost City Pays Monthly
24 Pay Periods
Employee Only $7.96 $0.00 $3.98
Employee + One $15.90 $0.00 $7.95
Employee + Family $21.26 $0.00 $10.63
Page | 13Basic Life & AD&D Benefits
Effective January 1, 2021
The City of Galveston provides Basic Life and AD&D (Accidental Death and Dismemberment) insurance for you as a
full-time employee at no additional cost. If you would like to purchase additional life insurance for yourself and/or
your dependents, please see the Voluntary Life Insurance page for more information.
BENEFICIARY INFORMATION
Remember, it is important to designate beneficiaries for all of your insurance policies that require them. If you
don’t, laws may cause death benefits to be distributed differently than you had planned resulting in additional taxes
and may unnecessarily delay the process of finalizing payment to your loved ones. You should regularly review and,
if necessary, update your beneficiary designations. You can update your beneficiary at any time.
BASIC LIFE/AD&D BENEFITS Standard Life Benefits
Class Description All Full-Time Active Employees
Working at least 40 Hours per Week
Basic Life & AD&D Schedule Two times Base Annual Earnings up to $400,000
Guarantee Issue For New Employees $400,000
Minimum Benefit $10,000
Employee Age Reduction Schedule To 65% @ Age 70, To 50% @ Age 75
Waiver of Premium Included to age 60
Accelerated Death Benefit Up to 75% of Life Benefit
Conversion Included
NOTE: This is a brief summary and not intended to be a contract.
Page | 14Voluntary Life & AD&D Benefits
Effective January 1, 2021
VOLUNTARY LIFE/AD&D BENEFITS Standard Life Benefits
Employee Life/AD&D Amount Increments of $10,000 up to $300,000
Employee Guarantee Issue Amount – New Employees $100,000
Employee Maximum Amount Lesser of 4 times base annual earnings or $300,000
Spouse Life/AD&D Amount Increments of $10,000 up to $300,000
Spouse Guarantee Issue Amount – New Employees $50,000
Spouse Maximum Amount Lesser of Employee’s Amount or $300,000
Employee & Spouse Age Reduction Schedule To 65% @ age 70, To 50% @age 75
Child Life Amount $2,000, $5,000 or $10,000 Options
Waiver of Premium Disabled prior to age 60
Accelerated Death Benefit Up to 75% of Life Benefit
Conversion Included
Age Rated Premium Employee & Spousal Rates per $10,000
(Rates based on Employee/Spouse Age) With AD&D
Life Rate: Up to 30 $0.93
30-34 $0.97
35-39 $1.14
40-44 $1.40
44-49 $2.10
50-54 $3.15
55-59 $4.91
60-64 $6.11
65-69 $8.70
70-74 $14.12
75+ $44.28
Child(ren) Life Rate $2,000 - $.46 / $5,000 - $1.15 / $10,000 - $2.30
NOTE: This is a brief summary and not intended to be a contract.
Page | 15Voluntary Permanent Life Insurance
Effective January 1, 2021
Voluntary Permanent Life Insurance Chubb Life Benefits
Guarantee Issue Defined Benefit: $50,000
Employee Guarantee Issue Conditional Guaranteed Issue: $125,000
Simplified Eligibility – Defined Benefit: $150,000
Conditional Guaranteed Issue: $125,000
Spouse Guarantee Issue
Simplified Eligibility – Defined Benefit: $150,000
Child Term Rider Coverage $25,000
Children
Waiver of Premium Included
50% of the death benefit not to exceed $100,000
Accelerated Death Benefit
Accelerated Death Benefit for Long Term Care with extension of benefits.
The max amount payable for LBT with long term care and extension of
Long Term Care
benefits is $450,000.
NOTE: This is a brief summary and not intended to be a contract.
Page | 16Aflac Voluntary Benefits
Voluntary Coverages Offered
• Accident Advantage
• Critical Care Protection – Plus Rider Available
• Cancer Care Assurance
• Short Term Disability
How Do You Enroll?
Contact our Aflac Representative
Ms. Roberta Wiedeman
Office Number: (713) 789-6920
Cell Number: (713) 449-2477
Email: rmw2@flash.net
Page | 17Employee Assistance Program (EAP)
Effective January 1, 2021
The Employee Assistance Program (EAP) can help you resolve problems that affect your personal life or
job performance. The Employee Assistance Program (EAP) is offered to all employees and immediate
family members through UT EAP. The EAP is paid for by the City of Galveston. It is a completely
confidential counseling program that covers issues such as:
• Legal / Financial
• Depression / Stress
• Drug / Alcohol Abuse
• Emotional Problems
• Financial Pressures
• Grief Issues
• Family / Relationship Problems
• Other Personal Concerns
EAP staff members are available 24 hours a day, 7 days a week, every day of the year by calling (713)
500-3327. Staff members are highly trained professionals with experience in family, personal, work
related and substance abuse issues.
UT EAP can also be reached through their website.
website www.mylifevalues.com
user name cog
password cog
Page | 18Making Enrollment Changes During the Year
What Constitutes a Qualifying Life Event?
Benefits Allowed to Change
Vol. Child Life
Beneficiaries
Supp. EE Life
Qualifying Life Event
Health Care
Vol. Sp. Life
Dep. Care
Medical
Dental
You have 31 Days from your
Vision
Documentation
Qualifying Life Event to Change
Coverage
Change in marital status: Marriage Certificate
∙ Marriage Divorce Decree
∙ Divorce or Annulment Final Court Document
√ √ √ √ √ √ √
∙ Legal Separation Notarized Statement of
∙ Domestic Partner Dissolution Disenrollment
∙ Death of Spouse Death Certificate
Change in the number of dependents: Birth Certificate, Hospital
∙ Birth Announcement Adoption
∙ Adoption √ √ √ √ √ √ √ Agreement
∙ Guardianship of a Child Court Decree for Guardianship
∙ Death of a Dependent Death Certificate
Provide Name, Social Security
Dependent Becomes Eligible √ √ √ √ √ √ √ √ √ Number, and Date of Birth for
dependents
Proof of Loss of Coverage,
Dependent Loses Other Coverage √ √ √ √ √ √ such as termination letter;
Certificate of Creditable Coverage
Proof of Coverage with start date
of
Dependent Gains Other Coverage √ √ √ √ √ √
benefits and name(s) of covered
dependents
A change in Employee's, spouse's, or Proof of loss of Coverage due to
dependent's work hours (including a employment status change, such as
√ √ √ √ √ √
switch between full and part-time a Certificate of Creditable Coverage
status) or letter from the company
Change in Dependent Care Costs √ Letter from your Day Care Provider
Court Ordered Dependent, add or Contact your Benefits Team
√ √ √ √ √ √ √
drop from coverage Directly
Page | 19Page | 20
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